| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,736 |
4,702 |
$209K |
| D0120 |
Periodic oral evaluation - established patient |
5,106 |
5,074 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
887 |
702 |
$120K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,577 |
1,564 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
589 |
402 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,037 |
2,022 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
2,671 |
2,637 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
792 |
778 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
1,090 |
1,079 |
$19K |
| D4910 |
|
140 |
140 |
$12K |
| D1206 |
Topical application of fluoride varnish |
556 |
542 |
$10K |
| D1120 |
Prophylaxis - child |
246 |
246 |
$7K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
131 |
$5K |
| D0391 |
|
13 |
13 |
$1K |